Indian J Otolaryngol Head Neck Surg

(July 2011) 63(Suppl 1):S23S24; DOI 10.1007/s12070-011-0176-z

CLINICAL REPORT

Intractable Anemia: A Case of Bleeding Nasal Cavernous

Hemangioma
Saurav Sarkar Amitabha Roychoudhury
B. K. Roychaudhuri

Received: 9 June 2008 / Accepted: 21 August 2008 / Published online: 11 April 2011
Association of Otolaryngologists of India 2011

Abstract Cavernous haemangioma of the nose is rare,

but when it occurs it usually presents with severe epistaxis.
This nasal pathology is mostly seen in adult patient
patients. Standard approach to dealing with such haemangiomas is surgical resection. A 30-year-old woman presented to General Physician with history of haemoptysis,
haematemesis and weakness. She was admitted for investigation of her severe anaemia. On examination there was
no obvious source of bleeding in the mouth or oropharynx,
and Upper GI endoscopy did not reveal any pathology. She
was referred to us after a trivial episode of epistaxis.
Anterior and posterior rhinoscopy did not reveal any
abnormality. Her extreme anxiety made indirect laryngoscopy and post-nasal space examination difficult but no
obvious abnormality was seen. Diagnostic nasal endoscopy
was done, and a small haemangiomatous mass was found
in the postero superior part of inferior turbinate. Excision
of the mass was done under local anaesthesia and sent for
histopathological evaluation. The mass on histopathology
came out to be Cavernous haemangioma.
Keywords Severe anaemia
Cavernous haemangioma

Endoscopic excision

S. Sarkar (&)
Department of Otolaryngology and Head Neck Surgery, Stanford
University Medical School, Stanford, CA, US
e-mail: kushalkushal79@rediffmail.com
A. Roychoudhury
B. K. Roychaudhuri
Department of Otolaryngology and Head Neck Surgery,
Vivekananda Institute of Medical Sciences, Ramakrishna
Mission Seva Pratishthan, Kolkata, India

Introduction
Cavernous haemangioma of the nose is rare [1]. It usually
presents with severe epistaxis. Cavernous haemangioma
rarely presents with haemoptysis or haematemesis. Unlike
many haemangiomas, cavernous haemangiomas of the
nose usually do not present until adulthood, with a mean
age of presentation of around 40 years of age. The standard
approach to dealing with such haemangiomas has been
surgical resection of the tumour, and ligation or cautery to
the feeding vessels [24].

Case report
A 30-year-old woman was seen on 17th September 2006,
after referral by her General Practitioner, with a 1-month
history of haemoptysis, haematemesis and weakness. This
occurred every morning, and also at other times throughout
the day, and consisted of moderate amounts of bright red
colour. Past medical, surgical, gynaecological history did
not reveal anything significant. She was admitted for
investigation. On examination there was no obvious source
of bleeding in the mouth or oropharynx. Anterior and
posterior rhinoscopy did not reveal any abnormality. Her
extreme anxiety made indirect laryngoscopy and post-nasal
space examination difficult but no obvious abnormality
was seen. The haemoglobin concentration was 5.9 g/dl
with a haematrocrit of 0.39. Chest X-ray was normal. Two
units of blood were transfused after proper cross matching.
Diagnostic nasal endoscopy was done and, a small haemangiomatous mass was found in the postero superior part
of inferior turbinate near the post fontanelle of the maxillary antrum. The mass was the size of 5 mm 9 5 mm. The
mass was excised under local anaesthesia, after which the

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Indian J Otolaryngol Head Neck Surg (July 2011) 63(Suppl 1):S23S24

Our case was unique in the sense that a haemangioma of

the size smaller than a pea (5 mm 9 5 mm) could produce
so much blood loss that the patient required transfusion [5].
Although the haemangiomatous mass was situated in the
nasal cavity it hardly produced symptoms of frank epistaxis
and the bleeding was mostly posterior producing symptoms
of haemoptysis and haematemesis, and despite all investigations rigid endoscopy provided the relevant information
and was helpful in treatment of the case [6].

Conclusion

Fig. 1 Histopathological examination

Cavernous haemangioma

showing dilated vessels

base was cauterized and it mass was sent for histopathological examination. Histopathological examination
revealed Cavernous haemangioma (Fig. 1).

Discussion
Cavernous haemangioma of the nose is rare. There has
apparently been only one case report of a cavernous haemangioma arising from the inferior turbinate, which was by
Shenoi 2 in 1973. His patient was a 36-year-old male, also
presenting with haemoptysis. The haemangioma was found
to be on the posterior end of the left inferior turbinate.
Cavernous haemangiomas of the nose are not typical of
haemangiomas elsewhere on, or in, the body. They tend to
present at a somewhat later age, around 40 years old, but in
our case the age of presentation was 30 years. Bridger [3]
in 1976 reviewed 18 cases from world literature, gender
was not documented for three patients, the remaining 15
showed a female to male ratio of 4:1. Our case was a
female of 30 years of age.

123

Cavernous haemangioma of the nose is rare. This may have

presentation, other than epistaxis. Otolaryngologists must
have a keen diagnostic eye to detect haemangioma of the
nose having atypical presentation like haematemesis,
haemoptysis or severe anaemia. Diagnostic nasal endoscopy is a very useful tool in all such cases of haemoptysis
and haematemesis with or without epistaxis.

References
1. Osborn DA (1959) Haemangiomas of the nose. J Laryngol Otol
73:174
2. Shenoi PM (1973) Cavernous haemangioma of the inferior
turbinate: a rare cause of haemoptysis. J Laryngol Otol
87:12291232
3. Bridger MWM (1976) Haemangioma of the nasal bones. J Laryngol Otol 90:191
4. Fahmy FF, Back G, Smith CET, Hosni A (2001) Osseous
haemangioma of inferior turbinate. J Laryngol Otol 115:417418
5. Beer HL, Duvvi S, Webb CJ, Tandon S (2005) Blood loss
estimation in epistaxis scenarios. J Laryngol Otol 119:1618
6. OLeary-Stickney K, Makielski K, Weymuller EA Jr (1992) Rigid
endoscopy for the control of epistaxis. Arch Otolaryngol 118:9